The future of foot and ankle analysis might reside in the development of promising new endoscopic techniques for tendinopathies – even though studies of a higher level of evidence are still required before this happens.
Arthroscopy has been the choice procedure for foot and ankle situations, but endoscopic approaches have been described as procedures for almost all the tendons around the foot and ankle. A foot and ankle tendoscopy is a relatively safe procedure, and orthopedic surgeons seem to be increasingly adopting this technique in their everyday practice.
A tendoscopy might be an excellent choice for the treatment of Achilles non-insertional tendinopathy, but the role of plantaris tendon release is not yet clear. This type of tendoscopy allows for the destruction of neonerves and neovessels surrounding the tendon, which may improve the pain. Another goal for the treatment of a non-insertional tendinopathy, such as, for instance, high-volume image-guided injections, is the destruction of abnormal neoinnervation. But there is still a lot of conflicting evidence regarding the use of high-volume injections for Achilles non-insertional tendinopathy.
Surgeons should then not consider the use of tendoscopy for acute ruptures as it may be associated with a higher morbidity and potential complications, with no significant improvement over conventional mini-invasive repair.
Despite this, a peroneal tendoscopy still seems to be useful in some cases, such as the resection of symptomatic peroneus quartus, as well as for the management of intrasheath peroneal subluxation and for fibular deepening in cases of instability and dislocation.
However, the most common indication for peroneal surgery – longitudinal tears – still needs an open approach for the repair.
Posterior tibial tendon synovectomy in stage I and II of the flatfoot deformities may benefit from tendoscopy, although conventional medial soft-tissue repair, most of the times, still needs an open approach. The posterior tibial tendon vinculum is apparently not associated with any specific function.
There is no explanation for pain resolution following endoscopic vinculum resection. There is a need for further studies in order to know the real significance of it.
There are some limitations for tendoscopy which you might want to remember next time you think about it. Bear in mind that extensive longitudinal tendon tears are difficult to repair using endoscopy as a main option. It is not quite possible yet, but who knows what the future holds.
A foot and ankle tendoscopy offers advantages over open procedures:
- Fewer wound infections;
- Less blood loss;
- Smaller wounds;
- Lower morbidity;
- Quicker recovery;
- Early mobilization and function;
- Mild post-operative pain;
- The possibility of being performed under local anesthesia on an outpatient basis.
Nonetheless, sufficient endoscopic skills are needed to avoid neurovascular and skin complications.
Foot and ankle tendoscopy has gained a certain degree of popularity among orthopedic surgeons. Further research in this area is required in order to have a more evidence-based approach. Tendoscopy might even allow for a future classification of different findings in and around foot and ankle tendons, as arthroscopy did. It is important to establish which findings are physiological or pathological possibilities.
In order to expand the use of this technique, new instruments dedicated to tendoscopy and proper surgical training in a safe environment are required, which will power the treatment of longitudinal tears, and new gadgets will possibly allow the harvesting of tendons whenever needed.
Tendoscopy is becoming an important diagnostic and therapeutic tool when dealing with selected indications in foot and ankle pathology.